History taking and physical examination an overview

History Taking and Physical Examination: An Overview

Companion eNotes: The Comprehensive History and Physical Examination Prepared and presented by Marc Imhotep Cray, M.D.

The Comprehensive H&P  Comprehensive H&P is typically obtained when a physician sees a patient for first time in a general medical setting, or when a patient is admitted to hospital  One exception is when pt. presents wan emergent complaint and initiating treatment is a higher priority than obtaining a detailed history or performing a thorough physical examination  Almost all other types of documentation, including SOAP (subjective, objective, assessment, and plan) notes and admission H&Ps, are variations of comprehensive H&P Marc Imhotep Cray, M.D.

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Learning Objectives: By the end of this presentation the learner should be able:  To understand the general principles of the approaches to the patient  To describe the seven components of the comprehensive adult medical history  To explain the essential components of preparing for the physical examination  To describe the equipment required for the physical examination  To list the general sequence of the physical examination  To describe the four cardinal techniques used in preforming the physical examination Marc Imhotep Cray, M.D.

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Approaches to Patient: General principles General Objectives When physician (or student) approaches a patient (pt.) there are four initial objectives: 1. Obtain a professional rapport with pt. and gain his confidence 2. Obtain all relevant information which allows assessment of illness, and provisional diagnoses 3. Obtain general information regarding pt., his background, social situation and problems  In particular it’s necessary to find out how the illness has affected him, his family, friends, colleagues and his life

4. Understand pt.’s own ideas about his problems, his major concerns & what he expects from hospital admission, outpatient or general practice visit Marc Imhotep Cray, M.D.

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Approaches to Patient: General principles(2) Specific objectives In taking a history (Hx) or making an examination (PE) there are two complementary aims: 1. Obtain all possible information about a pt. and his illness (a database) 2. Solve problem as to diagnoses

Marc Imhotep Cray, M.D.

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Approaches to Patient: GPs (3) Analytical approach  For each symptom (Sx) or sign (Sn) one needs to think of a differential diagnosis (DDx), and  of other relevant information (by history, examination or investigation) which one will need to support or refute these possible diagnoses Self-reliance  The student must take his own history, make his own examination and write his own clinical records Marc Imhotep Cray, M.D.

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Approaches to Patient: GPs (4) What is important when you start?  At basis of all medicine is clinical competence  No amount of knowledge will make up for poor technique

 It is essential to learn and practice the basic ABCs of clinical medicine, introduced in this clinical skills sequence:  how to relate to patients (communication skills)  how to take a good history efficiently, knowing which question to ask next and avoiding leading questions  how to examine patients in a logical manner, in a set routine which will mean you will not miss an unexpected sign  apply yourself  initially learn by rote which skills are appropriate for each situation Marc Imhotep Cray, M.D.

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Differences Between Subjective & Objective Data Subjective Data  What the patient tells you  The history, from Chief Complaint through Review of Systems

Objective Data  What you detect during examination  All physical examination findings  Also, laboratory test and other diagnostic/ investigative techniques

Example: Ms. G is a 54-year-old hairdresser who reports pressure over her left chest "like an elephant sitting there," which goes into her left neck and arm.

Example: Ms. G is an older, over-weight white female, who is pleasant and cooperative.

Height 5’4 weight 150 lbs., BMI 26, BP 160/ 80, HR 96 and regular, respiratory rate 24, temperature 97.5 F

Marc Imhotep Cray, M.D.

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“An History & Physical Exam” Caveat While a good deal of attention may be paid to patient’s physical examination, over years research has concluded that most of important information needed to make a diagnosis about what is wrong with patient comes from patient history  Thus, asking patient questions and listening carefully to what he or she says or does not say is often much more helpful than PE or results of laboratory tests which may just confirm what is learned during the history

Marc Imhotep Cray, M.D.

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History Taking Following we describe the seven components of the Comprehensive Adult Health History: 1. Identifying Data and Source of the History 2. Chief Complaint(s) 3. Present Illness 4. Past History 5. Family History 6. Personal and Social History 7. Review of Systems Marc Imhotep Cray, M.D.

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1. Identifying Data  Identifying data—such as full name, age, gender, occupation, marital status  Source of history—usually patient, but can be a family member or friend, letter of referral or medical records

 If appropriate, establish source of referral, because a written report may be needed Marc Imhotep Cray, M.D.

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3. Chief Complaint (CC) /Reliability ď ąVaries according to the patient's memory, trust and mood ď ąThe one or more symptoms or concerns causing the patient to seek care

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3. Present Illness (HPI)  Amplifies Chief Complaint; describes how each symptom developed  Includes patient's thoughts and feelings about the illness  Pulls in relevant portions of the Review of Systems, called “pertinent positives and negatives”  May include medications, allergies, habits of smoking and alcohol, which are frequently pertinent to the present illness Marc Imhotep Cray, M.D.

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4. Past History (PMH)  Lists childhood illnesses  Lists adult illnesses with dates for at least four categories:  Medical  Surgical  Obstetric/gynecologic  Psychiatric  Includes health maintenance practices such as immunizations, screening tests, lifestyle issues, and home safety Marc Imhotep Cray, M.D.

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Family History (FH) ď ą Outlines or diagrams age and health, or age and cause of death, of siblings, parents, and grandparents ď ą Documents presence or absence of specific illnesses in family, such as hypertension, diabetes, coronary artery disease , etc.

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Personal and Social History (PH & SH) Describes:  educational level  family of origin  current household  personal interests and  lifestyle/habits  religion/spiritual beliefs

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Review of Systems (ROS)  Documents presence or absence of common symptoms related to each major body system  Review of systems (or symptoms) is a list of questions, arranged by organ system, designed to uncover dysfunction and disease can be applied in several ways: 1.

2.

3.

As a screening tool asked of every patient that you encounters Asked only of patients who fall into particular risk categories (e.g. reserving questions designed to uncover occult disease of prostate to men over 50) To better define likely causes of a presenting symptom, as described in HPI section (e.g. patients w/a chief concern of "chest pain" would be asked detailed cardiac and pulmonary ROS)

 What's the best way to use ROS? Makes sense if following hold true: o Questions asked reflect an array of common and important clinical conditions o These disorders would go unrecognized if patient was not specifically prompted o Identification of these conditions then has a positive impact on morbidity/mortality Marc Imhotep Cray, M.D.

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The Comprehensive Adult Physical Examination Beginning the Examination: Setting the Stage  Before you begin the physical examination, take time to prepare for tasks ahead  Think through your approach to patient, your professional demeanor, and how to make patient feel comfortable and relaxed  Review measures that promote patient’s physical comfort and make any adjustments needed in lighting and surrounding environment See eNotes: Physical Diagnosis: Approach to the Patient (66 CORE ESSENTIALS in sequence, as to not have patient reposition unwarranted.)

Marc Imhotep Cray, M.D.

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Equipment for Physical Examination  An ophthalmoscope and an otoscope • If otoscope is to be used to examine children, it should allow for pneumatic otoscopy  A flashlight or penlight  Tongue depressors  A ruler and flexible tape measure, (marked in cm)  A thermometer  A watch with a second hand  A sphygmomanometer  A stethoscope with following characteristics: • Ear tips that fit snugly and painlessly. To get this fit, choose ear tips of proper size, align ear pieces with angle of your ear canals, and adjust spring of connecting metal band to a comfortable tightness • Thick-walled tubing as short as feasible to maximize the transmission of sound: approximately 30 cm (12 inches), if possible, and no longer than 38 cm (15 inches) • Imhotep A bellCray, and a diaphragm with a good changeover mechanism 19 Marc M.D.

Equipment for Physical Examination cont.        

Gloves and lubricant for oral, vaginal, and rectal examinations Vaginal specula and equipment for cytological and bacteriological study A reflex hammer Tuning forks, ideally one of 128 Hz and one of 512 Hz Q-tips, safety pins, for testing two-point discrimination Cotton for testing the sense of light touch Two test tubes (optional) for testing temperature sensation Paper and pen or pencil

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PE: Summary of Suggested Sequence    

General survey Vital signs Skin: upper torso, anterior and posterior Head and neck, including thyroid and lymph nodes

Optional: nervous system (mental status, cranial nerves, upper extremity motor strength, bulk, tone and cerebellar function)

 Thorax and lungs  Breasts  Musculoskeletal as indicated: upper extremities  Cardiovascular, including JVP, carotid upstrokes and bruits, PMI, etc.  Marc CV,Imhotep for S3 and murmur of mitral stenosis Cray, M.D.

 CV, for murmur of aortic insufficiency Optional: thorax and lungs-anterior

 Breasts and axillae  Abdomen  Peripheral vascular; Optional: skin-lower torso and extremities  Nervous system: lower extremity motor strength, bulk, tone, sensation; reflexes; Babinski  Musculoskeletal, as indicated Optional: skin, anterior and posterior Optional: nervous system, including gait Optional: musculoskeletal, comprehensive

 Women: pelvic and rectal examination  Men: prostate and rectal examination 21

Cardinal Techniques of the Physical Examination    

Inspection Palpation Percussion Auscultation

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Inspection Close observation of details of patient's:  appearance  behavior, and movement such as facial expression  mood  body habitus and conditioning  skin conditions such as petechiae or ecchymoses  eye movements  pharyngeal color  symmetry of thorax  height of jugular venous pulsations  abdominal contour  lower extremity edema and  gait Marc Imhotep Cray, M.D.

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Palpation Tactile pressure from the palmar fingers or finger pads to assess:  areas of skin elevation or depression  warmth, or tenderness  lymph nodes  pulses  contours and sizes of organs and masses and  crepitus in the joints

Marc Imhotep Cray, M.D.

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Percussion  Use of striking or plexor finger, usually third digit, to deliver a rapid tap or blow against distal pleximeter finger, usually distal third finger of left hand laid against surface of chest or abdomen, to evoke a sound wave such as resonance or dullness from underlying tissue or organs • This sound wave also generates a tactile vibration against pleximeter finger

Marc Imhotep Cray, M.D.

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Auscultation Use diaphragm and bell of stethoscope to detect characteristics of:  heart  lung and  bowel sounds including: location, timing, duration, pitch, and intensity • For heart this involves sounds from closing of four valves and flow into the ventricles as well as murmurs  Auscultation also permits detection of bruits or turbulence over arterial vessels Marc Imhotep Cray, M.D.

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Comprehensive Hx and PE Capsule History of Present Illness (HPI) The Rest of the history: Past Medical History(PMH) Past Surgical History (PSH) Medications (Meds.)

Allergies/Reactions Social and Personal History: (Smoking, Alcohol, Drugs of abuse) Obstetric (where appropriate) Sexual Activity Family History (FH) Work/Hobbies/Other Military Service Adult Review of Systems (ROS) Marc Imhotep Cray, M.D.

General Appearance Vital Signs (VS) Eye Exam HEENT Head and Neck Exam Lung Exam Cardiovascular Exam Exam of the Abdomen Breast Examination Male Genital and Rectal Exam Exam of Upper Extremities Exam of Lower Extremities Musculo-Skeletal Examination Neurological Examination 27

The “differential of consequence” (DOC) Develop a focused differential of things that may kill the patient or that you cannot afford to miss This is called the “differential of consequence” (DOC)  For example, if your pt. comes into ED w left-sided chest pain, don’t waste time and energy on ruling out shingles o Instead, focus on things like MI, pulmonary embolism (PE), pneumonia, and pericarditis  Once you have your DOC think of which tests you can order in ED to confirm these conditions or rule them out  Bear in mind, however, that tests ordered in ED must have a quick (less than 2-hour) turnaround time Marc Imhotep Cray, M.D.

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The History and Physical Examination: Comprehensive or Focused?

Comprehensive Assessment  Is appropriate for new patients in office or hospital  Provides fundamental and personalized knowledge about patient  Strengthens the clinician-patient relationship  Helps identify or rule out physical causes related to patient concerns  Provides baselines for future assessments  Creates platform for health promotion through education and counseling  Develops proficiency in the essential skills of physical examination Marc Imhotep Cray, M.D.

Focused Assessment  Is appropriate for established patients, especially during routine or urgent care visits  Addresses focused concerns or symptoms  Assesses symptoms restricted to a specific body system  Applies examination methods relevant to assessing concern or problem as precisely and carefully as possible 29

Summary of the Diagnostic process Step 1: Take a History: Elicit symptoms and a timeline; begin a problem list.

Step 2: Develop Hypotheses: Generate a mental list of anatomic sites of disease, pathophysiologic processes, and diseases that might produce the symptoms.

Step 3: Perform a Physical Examination: Look for signs of the physiologic processes and diseases suggested by the history, and identify new findings for the problem list.

Step 4: Make a Problem List: List ALL the problems found during the history and physical examination that require an explanation.

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Summary of Diagnostic process(2) Step 5: Generate a Differential Diagnosis: List the most probable diagnostic hypotheses with an estimate of their pretest probabilities.

Step 6: Test the Hypotheses: Select laboratory tests, imaging studies, and other procedures with appropriate likelihood ratios to evaluate your hypotheses.

Step 7: Modify Your Differential Diagnosis: Use the test results to evaluate your hypotheses, eliminating some, adding others, and adjusting the probabilities.

Step 8: Repeat Steps 1 to 7: Reiterate your process until you have reached a diagnosis or decided that a definite diagnosis is neither likely nor necessary.

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Summary of Diagnostic process(3) Step 9: Make the Diagnosis or Diagnoses: When the tests of your hypotheses are of sufficient certainty that they meet your stopping rule, you have reached a diagnosis.

If uncertain, consider a provisional diagnosis or watchful waiting. ď ś Decide whether more investigation (return to Step l), consultation, treatment, or watchful observation is the best course based upon the severity of illness, the prognosis, and comorbidities.

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THE END

See next slide for links to tools and resources for further study.

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Sources and Further Study: Cloud Folders Introduction to Clinical Medicine I (ICM-1) Introduction to Clinical Medicine II (ICM-2) Bate’s Guide to the Physical Examination and History Taking, Lynn Bickley (with Video) DeGowin’s Diagnostic Examination, 9th Ed. Richard DeGowin,et al.

Textbook of Physical Diagnosis: History and Examination, Mark Schwartz. (with Video) A Practical Guide to Clinical Medicine, Charlie Goldberg and Jan Thompson.

(A PDF version of the website compiled by this presenter.)

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